Practical Approach to Care Kit: Innovation for nurses’ clinical practice in HIV management

Abstract Objective: to analyze the use of the Practical Approach to Care Kit as a technology adopted in nurses’ clinical practice for HIV management in Primary Health Care. Method: an exploratory and descriptive research study anchored in the methodological framework of the Constructivist Grounded Theory. The participants were defined through initial sampling, with 12 nurses, and theoretical sampling, with five managers, totaling 17 participants. The data were collected by means of intensive interviews and documentary analysis, and they were analyzed in two stages: 1) Initial coding; and 2) Focused coding. Results: the professionals identified the Practical Approach to Care Kit as a technological innovation that contributed to expanding the clinical practice and to empowering nurses in the clinical management of HIV infection. They also highlighted its importance as a tool for guiding the different responsibilities and duties while sharing care, contributing to the provision of evidence-based practices. Conclusion: The Practical Approach to Care Kit is a technological innovation that has transformed nurses’ clinical practice in HIV management, expanding their scope of activities in carrying out the diagnosis, assessing the health condition and counseling, evaluating adherence to the treatment, adverse effects and prescription of exams, medications, and immunobiological.


Introduction
Nurses' clinical practice has exerted a positive impact on health care in the scope of Primary Health Care (PHC) and encompasses care and clinic management actions, involving a complex set of activities supported by evidence-based practices and the use of management microtechnologies (1)(2)(3) .
A new care model for people living with HIV has been discussed and implemented gradually in the health services This model highlights PHC and turns care into a center for reorienting the HIV management practices, encompassing structuring elements that should be part of the care practices, such as: risk stratification model; qualification of professionals; technical support guarantee; providing access to CD4 and viral load (VL) tests; and enabling access to antiretrovirals (ARVs) (4) .
Although the HIV epidemic in Brazil is considered stable, the infection became a chronic condition that requires the adoption of technologies that strengthen the care practices and strategies for this population segment (4)(5) . These technologies can be of the material type, such as instruments, tools and devices, or the non-material type, including new ways to organize work, processes, and flows (6) . The technologies present in the health workspace can materialize in the production of relationships between subjects and in knowledge construction, and express themselves in changes in the organizational structures of the health services (7)(8) .
The Practical Approach to Care Kit (PACK) was developed at the University of Cape Town in South Africa and consists of a tool based on recent scientific evidence and global health care recommendations. Its structure is based on four pillars: 1) Guide of clinical guidelines; 2) Professional training strategy; 3) Monitoring; and 4) Implementation of changes for the health system (9)(10) .
The Adult Brazil PACK consists of a technology used in nurses' clinical practice in PHC, a concise tool to support clinical decision-making, which resorts to algorithms based on symptoms and a standardized checklist to assist physicians and nurses in the evaluation, counseling, and treatment of health conditions (4,9) .
The municipality of Florianópolis, Santa Catarina/ Brazil, was the first to implement PACK in the country.
Using this technology has contributed to the improvement of teamwork, sharing of care, expansion of the nurses' clinic, and professional training for the management of the main diseases monitored in PHC, such as HIV (10)(11) .
Other international contexts also contribute to successful experiences in using the PACK (12)(13) .
In view of the above, and considering that the guidelines for the decentralization of HIV care are recent and that, up to date, the clinical management guidelines prepared by the Brazilian Ministry of Health are directed to medical professionals (4) , the need is identified to carry out studies that deal with nurses' role in the management of people living with HIV in PHC. Consequently, the objective of this study is to analyze the use of the Practical Approach to Care Kit as a technology adopted in nurses' clinical practice for HIV management in Primary Health Care.

Method Study type and design
This is an exploratory and descriptive research study of a qualitative nature, anchored in the methodological framework of the Constructivist Grounded Theory (GT), which seeks to analyze experiences and interactions in order to understand meanings attributed to a phenomenon (14) .
The constructivist strand has symbolic interactionism and social constructivism as its philosophical bases, which presuppose the elaboration of a theory through contact between researcher and participants, allowing data cocreation. Thus, multiple realities and social interactions are acknowledged as important to build the interpretations, in order to urge the researchers' reflective ability in relation to their analyses (14) .
This manuscript followed the guidelines set forth in the Consolidated criteria for reporting qualitative research (COREQ) (15) .

Data collection locus
The study was conducted in the municipality of Florianópolis, which presents the highest Human Development Index (HDI-M) among the capital cities of the country (0.847). In 2020, the health-related expenses were R$ 811.73 per inhabitant/year. In July 2021, Florianópolis had a total of 150 Family Health Teams, reaching 77.30% of population coverage (16) . The municipal network has 49 Health Centers (HCs) distributed across 4 health districts (17) .

Selection criteria
The definition of the study participants was first carried out by means of initial sampling and, subsequently, through theoretical sampling, which guides the search for places, actors, and events that enhance the findings and formation of the analysis categories, filling the gaps that arise throughout the research (14) . In the initial sampling, the criteria for selecting the participants and collecting/ analyzing preliminary data are established, whereas in the theoretical sampling, conceptual and theoretical refinement of the data is sought.
The groups of participants were intentionally selected, considering their performance in the PHC services and use of the PACK, as well as their contribution to the process of implementing the technological innovation.
The following were defined as inclusion criteria for the initial sampling group: 1) working as a clinical nurse, coordinator, or resident in PHC; and 2) having at least six months of experience in PHC in relation to the data collection date. For the second group theoretical sampling, the inclusion criterion defined was having worked in the Florianópolis SMS management area for more than six months in relation to the data collection date. For both sampling groups, the exclusion criterion considered corresponded to the professionals who were distanced from work during the data collection period, regardless of the reason.
After applying the inclusion and exclusion criteria, the participants were randomly invited to participate in the research, with no prioritization and/or sorting criteria in this stage.

Participants
In the initial sampling group, 12 nurses who worked in four PHC health centers were interviewed, representing 75% of all the active nurses in these services (n=16).
In the theoretical sampling group, five managers who worked in the specialized care, clinical management, care integration, and epidemiological surveillance SMS sectors were interviewed.  (14) .

Instruments used for data collection
During the interviews, the participants were alone in their rooms, and a few of them were interrupted by co-workers to deal with emerging demands, not causing harm to data collection and analysis. Some nurses

Data analysis
For the analysis, the data were introduced and organized into the Atlas.ti software, version 9.0, following the guidelines set forth in the Constructivist GT. Data analysis followed two coding phases: 1) Initial coding; and 2) Focused coding. In the first phase, the incidents were coded in order to understand the diverse information based on the participants' meanings and experiences, constituting the first conceptual dimensions of the analyzed experience. In the second phase, the most expressive codes were grouped to give rise to 28 abstract categories and synthesize the data fragments (14) . Memos and diagrams were also prepared to aid analytical data development.
For Charmaz, the constant data comparison process in the GT strengthens the assertions about the implicit data and contributes to reducing the risk of bias in data analysis (14) .

Characterization of the participants
Of the 12 participants from the first sampling group, two (16.6%) were male and 10 (83.3%) were female.
Eight (66.6%) worked as clinical nurses, two (16.6%) as coordinating nurses, and another two (16.6%) as resident nurses. The mean age of the group was 37 years old.
Regarding the schooling level, two (16.6%) were MSc and 10 (83.3%) were specialists. The mean time working in the service was three years.
Of the five participants from the second sampling group, two (40%) were male and three (60%) were female. The mean age was 41 years old. Regarding the schooling level, two (40%) were MSc and Ph.D. All five participants were graduates in Medicine and had some specialization. The mean time working in the service was three years. All of them held positions in the higher SMS management instances.

as a technological innovation for nurses' clinical performance in HIV management
The PACK emerged as a technology that allows     In synthesis, the core elements of the phenomenon under study signal use of the PACK as a technological innovation in management of the HIV infection. Figure 1 presents a synthesis of the main elements of the phenomenon under study. As can be seen, the data found made it possible to identify processes and practices indicating a reorganization of the nurses' work process, with consequent advances for their clinical practice within the PHC scope.

Discussion
The findings of this study allow characterizing the PACK as a non-material technological innovation of an incremental and process type (18) , which led to reorganization of the work performed in PHC services.
Using the technology in HIV infection management enabled greater empowerment of nurses for the clinical followup of this health problem and favored interprofessional practices through shared care and decision-making.

Another study identified that PHC nurses from
Florianópolis prefer to use Nursing protocols as a basis for carrying out their clinical practices, as they understand that they are frequently updated and guarantee greater legal support for their work (19) . The PACK's clinical guidelines are conceptually aligned and updated with the municipal protocols, therefore, they constitute important technologies that guide the care of this health condition.
The clinical guidelines contained in the PACK evidence the specific activities of physicians and nurses alike, as members of the multiprofessional health team, guiding shared care and approaching interprofessional practices. In this logic, the literature indicates that nurses' empowerment in the clinical practice is a core attribute for the development of competencies that involve decision-making in health, supported by the provisions of manuals, lines of care or specific or multiprofessional clinical protocols (20)(21) . Clinical protocols and guidelines are crucial to provide safe and quality health care (22) . conferring greater resoluteness to PHC services (4) .
Such improvements demand qualification of the care provided by nurses; in this sense, using care guides and protocols in PHC, such as the PACK, expands nurses' clinical performance and, consequently, the proportion of users who can be monitored by these professionals. A study carried out on PACK implementation records that its use provides more resolute care and resource optimization (23) .
Another study, which analyzed implementation of the PACK in Brazil, pointed out that some nurses were resistant to expanding the scope of their practices and to the increase in workloads, as well as the physicians felt threatened with the expansion of nurses' clinical performance. However, the explanation about delineation of the clinical roles and functions provided confidence and general acceptance toward the tool (10) .
The PACK was developed for the South African reality, where there were no physicians available to manage the most frequent diseases in PHC, including clinical management of HIV, which led to the expansion of nurses' clinical role. International experiences of PACK implementation highlight good results achieved by using the technology (23)(24)(25) . In South Africa, improvements in care quality and in indicators such as prescription, referrals and case detection stand out, mainly in relation to communicable diseases. There are also good results related to health follow-ups and economic benefits, such as a reduction in the number and length of hospitalizations (23) .
In the same sense, in Pakistan, a study interviewed physicians, nurses and paramedics, and the results indicate high levels of acceptance of the PACK among health professionals, with emphasis on training initiatives and the protocol structure (25) . In Nigeria, the health professionals' experience with the PACK was also positive in terms of ease of use, usefulness during the appointments, better ability to diagnose and manage patients, better cost-effectiveness (less polypharmacy and fewer exam requests), more confidence and appreciation of their professional performance (24) . Based on this diverse evidence, the PACK can be characterized as a successful innovation that expanded nurses' clinical practice in the countries where it was implemented.
With regard to the PACK implementation process in Brazil, a study historicizes this process, noting that it began in 2014 and comprised different stages (10) .
The first was the local engagement stage, which lasted approximately one year, where conversations were started to define the scope, financing, contracting and definition of those responsible for conducting the project in Brazil.
At a second moment, the PACK was introduced, where the analysis of its principles and mentoring model was advanced, as well as a visit to South Africa to learn about the experiences using the tool (10) . The results of the current study show that organizing the PACK in a flowchart format, with guidelines based on diverse scientific evidence, allowed for safe clinical decision-making during the care provided to people living with HIV. The scientific literature points out that using evidence-based instruments for care planning contributes to the adoption of safe and good quality practices, which is a priority recommendation for patient safety in health institutions (29) . The literature also records the importance of developing and incorporating low-cost technologies in PHC, to expand access, reduce costs and promote effectiveness of the services (30) .
A technological innovation can be understood as a change that breaks with traditional patterns in the production process in any sector of the economy (18) .
The health field has been strongly influenced by the innovation process, including a wide diversity of material technologies and also new care modalities with a view to implementing improvements in health work processes and/or products (6,31) . The findings of this study allow conceptualizing the PACK as an innovative, non-material, process and incremental technology. This understanding is justified because it allowed realigning nurses' clinical www.eerp.usp.br/rlae In this logic, it is suggested to expand use of the PACK to other Brazilian regions and municipalities, in order to strengthen the PHC services and contribute to structuring a decentralized care network for people living with HIV. In addition, the results highlight the importance of investing in the production of innovative technologies that strengthen the right to health and the provision of good quality care.